Anne C. Roulo, DC 7501 Murdoch Ave, Shrewsbury, MO, 63119 314.484.0690 Patient Data Sheet Date Name: Address: City: State: Zip: Social Security Number: - - Email: Home Phone: ( ) Cell Ph.: ( ) Work Ph.: ( ) Gender: M F Date of Birth: Age: Marital Status: S M D W Work Status: Full time Part time Retired # of Children Employer: Occupation: Employer Address: City: State: Zip: Name of Spouse or Partner. For Minors, Name of Parent or Guardian: Age: Employer: Occupation: Employer Address: City: State: Zip: Work Phone:( ) In case of emergency contact: Relationship: Do you have Medicare insurance? Y N Plan/Group #: List chiropractors you have seen previously How did you find us, and may we thank someone for referring you? We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. 1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment. 1
2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions. 3. A patient's written consent need only be obtained one time for all subsequent care given the patient in this office. 4. The patient may provide a written request to revoke consent at any time during care. This would not effect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented. 5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them. 6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures. 7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care. I have read and understand how my PHI will be used and I agree to these policies and procedures: Consent to Services: I authorize Dr. Anne C. Roulo to perform examinations, diagnoses, x-rays (when necessary), chiropractic adjustments, physiotherapy, and other appropriate health care procedures. I will have the opportunity to ask questions about the nature and purpose of such procedures, and any possible risks and alternative procedures. I have the right to refuse any procedure. Cancellation Policy We expect that you will give 24 hours notice when cancelling or rescheduling an appointment. - Late cancellations will incur a $25 fee. The fee will be waived if the appointment is rescheduled and kept within one week. Emergency situations or extenuating circumstances will be dealt with on a case by case basis. - Missed appointments will be charged the full price of an adjustment. I understand that payment is due in full at time of service unless prior arrangements have been made. Fees are based on upon individual services and may vary from visit to visit. I agree to pay in full at the time of service and will file my own insurance. Reimbursement is determined by my contract with my insurance company. 2
Health History: Habits: Drinks/day Alcohol Tobacco: Packs/day Soda/diet soda Stress level: High Mod Low Coffee/tea Sleep: 8+ hrs 6-8 hrs 4-6 hrs < 4 hrs Sweetener Exercise: 5-7x/wk 3-5x/wk 1-3x/wk Water intake 64+ oz 32-64 oz none Type (per day) 16-32 oz 8-16 oz Meals/day: 5 4 3 2 1 < 8 oz Veggies and fruits/day: 5 4 3 2 1 1 glass = 8-12 oz Diet -Do you feel your diet is adequate? Y N -Are you on a special diet or particular diet? Y N If yes explain -How long has it been since you felt really good? Days Weeks Months Years >10 years -What is your general state of health? Excellent Good Fair Poor -Please rate how serious you are about getting well (scale of 1-10) -Please rate how serious you are about staying well (scale of 1-10) -Are you willing to follow a treatment plan designed to help you return to health? Y N -Are you willing to take supplements and make dietary changes? Y N Medications: Please check and list all medications that you are currently taking with the date you began taking them. Medication Name Date Started Antacids Antibiotics Anti-depressants Anti-diabetics Anti-inflammatory Blood pressure lowering meds Cholesterol lowering meds Hormone Replacement (HRT) Oral contraceptives Over-the-Counter Other Other Do you take vitamins/supplements or herbs? Y N Please list: Allergies: Please list all allergies. Food: Medications: Seasonal/Other: 3
Please list any surgical procedures, hospitalizations, and automobile accidents or other traumas. Please mark with an X any illnesses that you have now or have had in the past. Also, identify any conditions your family members have now or have had in the past. G = Grandparents, M = Mother, F = Father, S = Siblings Arthritis Blood pressure problems Heart disease Anemia or other blood disorder Diabetes or hypoglycemia Kidney disease Bladder problems Gall bladder problems Hepatitis Colon disease Ulcers Headaches Emphysema Gout Asthma Pneumonia Tuberculosis Muscle disorders Neurological Problems Immune system problems Tumors: non-cancerous Cancer HIV/AIDS Anxiety Cold sores Alcoholism Drug Abuse Deep vein thrombosis Epilepsy Stroke Osteoporosis 4
Symptoms: Please mark P (past) or C (current), and circle any that are of particular concern to you. General Convulsions Confusion Dizziness Fatigue Loss of sleep Loss of weight Nervousness Numbness Sweats Weakness in limbs Fever Pain Over Stomach Constipation Diarrhea Colon Trouble Hemorrhoids Liver Trouble Jaundice Gall Bladder Trouble Asthma Frequent Colds Enlarged Thyroid Tonsillitis Sinus Trouble Muscles and Joints Twitching Stiff Neck Backache Swollen Joints Tremors Foot Trouble Painful Tailbone Pain between Shoulders Hernia Spinal Curvature Gastro-intestinal Poor Appetite Poor Digestion Excessive Hunger Belching Foul Gas Nausea Vomiting Vomiting or Blood Women Only Painful Periods Excessive Flow Irregular cycle Hot Flashes Cramps or Backache Miscarriage Vaginal Discharge Fertility Problems Pregnant? Yes No Nursing? Yes No Cardiovascular Rapid Heart Slow Heart High Blood Pressure Low Blood Pressure Pain over Heart Stroke Poor Circulation Ankle Swelling Hardening of Arteries EENT Poor Vision Crossed Eyes Pain in Eyes Deafness Earache Ear Noises Ear Discharge Nasal Obstruction Nose Bleeds Sore Throats Horseness Hay Fever Skin Skin Eruptions Itching Bruise Easily Dryness Boils Sensitive Skin Eczema Varicose Veins Respiratory: Chronic Cough Spitting Blood Spitting Phlegm Chest Pain Difficulty Breathing Genito-urinary Frequent Urination Painful Urination Blood in Urine Kidney Infection Bed Wetting Inability to control urine Prostate trouble Decreased Libido Health Concerns: Please list your top health concerns in order of priority. 1. 2. 3. 4. 5
What type of treatment are you looking for? Please check all that apply. I am looking for the most minimal amount of care to patch up the symptoms of my condition. I am looking to resolve my symptoms, and then go on to address the cause of my condition. I am looking to resolve my symptoms, achieve optimal health, wellness, and disease prevention. Please check all that apply: I have a health condition, I am concerned and I don t know what it is. I have a medical condition and am receiving medical treatment and am unhappy with my results. I have a medical condition and wish to enhance my medical treatment. I have been to other doctors and/or chiropractors and continue to have health problems and wish to see if Dr. Roulo s approach will help me. I am currently on medications/drugs and wish to get off them. If yes, have you suggested this to the prescribing physician? I am currently on medications/drugs and wish to stay on them. I wish to discontinue medical treatment and am seeking an alternative method. Primary Concern: Location and severity of pain: Indicate the location and type of pain on the drawing using the following symbols: Dull xxxxx Cramping ///// Sharp/stabbing Burning 00000 Tingling ///// Numbness +++++ On a scale of 1 to 10, with 1 representing minimal pain, and 10 representing unbearable pain, how would you rate your pain? -Is your concern a result from: an auto accident? an injury at work? another accident? -Has another doctor treated you for this condition? Y N When? -Type of treatment -Is this condition interfering with your: Work Sleep Daily Routine Recreation Other: -What do you believe is wrong with you? 6